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Schedule of Benefits
1
Accident Insurance Provides
24-Hour Coverage
Initial Care
Hospital Benefits
Admission Benefit (per admission)
$1,500
Confinement Benefit (per day up to 365 days)
$200
ICU Benefit (per day up to 15 days)
$400
Emergency Room Treatment
$200
Ambulance
Ground
$200
Air
$1,000
Initial Doctor’s Office Visit
$100
Lodging
(per night up to 30 days per accident)
$100
Surgery Benefit
Open, abdominal, thoracic
$1,250
Exploratory
$125
Blood, Plasma and Platelets
$300
Emergency Dental Benefit
Extraction
$50
Crown
$150
Follow-Up Care
Accident Follow-Up Treatment
$100
Physical Therapy
Up to six visits per person per accident
$50
Appliance
$150
Transportation
100+ miles, up to three trips
$375
Prosthetic Device or Artificial Limb
More than one
$1,000
One
$500
Skin Grafts
25% of applicable
burn benefit
Accidental Death
Employee
$25,000
Spouse
3
$10,000
Child
$5,000
Accidental Death – Common Carrier
Employee
$50,000
Spouse
3
$20,000
Child
$10,000
Catastrophic Accident
Employee
$100,000
Spouse
3
$50,000
Child
$50,000
Injuries
Fractures
Open reduction
Up to $7,500
Closed reduction
Up to $3,750
Chips
25% of applicable
closed reduction
Dislocations
Open reduction
Up to $4,000
Closed reduction
Up to $2,000
Laceration
Up to $800
Burns
Flat amount for:
Third-degree 35 or more sq. in.
$10,000
Third-degree 9-34 sq. in.
$1,500
Second-degree for 36%
or more of body
$750
Concussion
$100
Eye Injury
Requires surgery or removal of foreign body
$200
Herniated Disc
$600
Loss of Finger, Toe, Hand, Foot or Sight
Loss of both hands, feet, sight of both eyes
or any combination of two or more losses
$15,000
Loss of one hand, foot or sight of one eye
$7,500
Loss of two or more fingers, toes or any
combination of two or more losses
$1,500
Loss of one finger or one toe
$750
Tendon/Ligament/Rotator Cuff Injury
Repair of more than one
$1,200
Repair of one
$800
Exploratory surgery without repair
$200
Torn Knee Cartilage
$500
Exploratory surgery
$100
Health Screening Benefit
One Per Person Per Year
$100
Routine health screening tests
1
Benefits are payable only as the result of a covered accident. Benefits may vary by state and additional benefits may be
available in some states. Most benefits are paid once per person per covered accident unless otherwise noted.
3
In some
states, spouse, domestic partner or civil union partner.
AP4-24-ADB-CAT-HSR100 Insert
BI WEEKLY RATES
(assumes deductions 26 per year)
Rate
$6.56
$9.77
$12.45
$15.67
Employee
Employee/Spouse Employee/Children Family
STANDARD PLAN